Respecting Body-Size Diversity in Patients: A Trauma-Informed Approach for Clinicians

Weight biases are negative attitudes, beliefs, judgments, stereotypes, and discriminatory acts aimed at individuals because of their weight. Such bias is ubiquitous in American society and represents a serious form of marginalization.¹ An abundant evidence base attests to its harmful effects, which include increased depression, anxiety, substance use, social isolation, and a blunted cortisol response due to chronic “toxic stress” that dysregulates the hypothalamic–pituitary–adrenal axis.^2,3 This stress is often exacerbated along axes of marginalized identities such as gender, race, sexual orientation, and socioeconomic status.^4–6

Unfortunately, weight bias is also entrenched in health care settings, influencing clinicians’ attitudes and behaviors, the medical community’s perception of the underlying factors informing body size, and, ultimately, patients’ experiences with care. Set against the backdrop of cumulative exposure to societal weight stigma, which itself constitutes a form of trauma, negative encounters in the health care system can be retraumatizing for patients. Just as weight bias is enacted at multiple levels within medicine, so too are opportunities for addressing it with a sensitive approach. Here, this paper discusses how the clinician can alleviate harms in patient encounters by using a trauma-informed lens.

Many clinicians hold strong, negative attitudes toward patients with large body sizes (though some may prefer different descriptors and thus our language is evolving).^7,8 These beliefs are often reinforced throughout medical training and can directly impact clinicians' behavior.^9,10 When caring for patients with large bodies, clinicians tend to conduct shorter exams, offer less education, and even exhibit contemptuous, patronizing, or disrespectful communication.^8,11 Patient narratives illustrate how medical practitioners' behaviors and the clinical milieu invoke feelings of shame and negative self-worth.^12–14 As a result, patients exposed to weight bias may mistrust doctors, avoid care, and be less likely to follow treatment recommendations.⁸ Practitioners of size may also feel discomfort during conversations about eating, exercise, or body size.¹⁵ Furthermore, the intersectional nature of weight bias can foster further mistrust among communities that have historically been treated unjustly by the institution of medicine.

Weight bias may also encourage a myopic view of patient presentations. Some patients describe frustrating instances of intersectional stigma in which clinicians link any expressed health concerns to their weight, a phenomenon dubbed “fat broken arm syndrome” in academic literature.⁵ These attitudes contribute to an overreliance on seemingly objective assessments of body size, such as body mass index (BMI).¹⁶ In addition to being misleading, such metrics are also informed by biases. Scholar Sabrina Strings traces the complex history of BMI to racialized notions about body size that originated during the eugenics movement and encompassed beliefs that “fatness [is] a constitutional flaw” and “the ‘low’ types…[are] prone to a lamentable ‘racial obesity.’”¹⁷

More broadly, weight bias also impacts how practitioners interpret and address the factors contributing to a patient’s body size. In recent years, the medical community has made progress in broadening its understanding of body size to include factors like socioeconomic status, access to food, and physical inactivity.¹⁸ However, clinicians may still overlook other important aspects of a patient’s history. For example, body size may be intimately connected to various elements of a patient’s identity, such as gender and/or cultural expectations about body shape. A transgender man may notice that he is misgendered less often when his body is larger, prompting him to gain weight intentionally. In this instance, body size serves as a mode of protection; reflexively prescribing weight loss rather than exploring the complexities of this patient’s story would do him a disservice.

Similarly, clinicians may not recognize the connection between trauma and the body. Decades of research show that body size is strongly associated with adverse childhood experiences (ACEs). In fact, the original Kaiser Permanente ACE study stemmed from Dr Vincent Felitti’s tenure in a weight loss clinic, where he noticed that many of his patients had histories of childhood trauma that profoundly impacted their relationships with their bodies. For example, one patient described weight gain as a means of protection following sexual assault, stating that being “overweight is overlooked, and that’s the way I need to be.”¹⁹ A recent meta-analysis of studies examining this link found that individuals with a history of ACEs were significantly more likely to have large bodies as adults (odds ratio 1.46 [confidence interval [CI] = 1.28, 1.64]).²⁰ This connection is explained in part by metabolic and neurocognitive effects of toxic stress, its intersection with the structural factors referenced above, as well as disordered eating as a coping mechanism.²¹ Although not all people with large bodies have a history of ACEs, clinicians must broaden their understanding of body size to acknowledge the possible impact of trauma. Medicine’s current framework for approaching issues related to body size does not consider this reality. Instead, its array of weight loss interventions offer downstream solutions that fail to address the root of the issue.

In the past 5 years, Nature and the Lancet have issued calls to action highlighting the negative impact of weight bias in medical settings.^2,22 These realities point to the need for enhanced training across the medical education trajectory to prepare clinicians to address body size and its associated health impacts more sensitively within the scope of the medical encounter. One strategy has been to educate students about the structural and biological components of weight in an effort to shift blame away from individual patients.^23,24 However, these interventions alone tend to reinforce the pathologization of large bodies without necessarily fostering empathy for the patients themselves.²⁵ Indeed, many doctors report that they have been exclusively taught to address excess weight as a serious and legitimate health risk and that avoiding discussions of weight would violate their obligation to “do no harm.”²⁶

Here, this paper offers an alternative: a framework grounded in the principles of trauma-informed care (TIC). TIC encourages clinicians and health systems to recognize the deleterious impact of trauma and develop universal practices to mitigate retraumatization and promote recovery. The Substance Abuse and Mental Health Services Administration (SAMHSA) outlines six domains that guide TIC: 1) safety; 2) trustworthiness and transparency; 3) peer support; 4) collaboration and mutuality; 5) empowerment, voice, and choice; and 6) cultural, historic, and gender issues. TIC encourages clinicians to reconceptualize the clinical encounter as an opportunity for understanding what has happened to patients, instead of simply identifying what is wrong with them. This reframing allows clinicians to move beyond problematizing, and toward affirming, the bodies our patients inhabit.

This approach is especially relevant for navigating clinical discussions about weight. Rather than avoiding such conversations altogether, TIC can be a way to acknowledge the impact of weight stigma and the health care practitioner’s obligation to address sensitive topics like weight, healthy eating, and physical activity if pertinent to the visit agenda. When considering how to implement this practice, students and clinicians can begin by reflecting on the role that SAMHSA’s six principles may play in an encounter:

• Safety: How might my patient’s past experiences with trauma and weight bias (both in medical settings and elsewhere) inform their feelings of safety during their appointment? How might my behavior, as well as my clinic’s policies and physical structure, contribute to this?

• Trustworthiness and transparency: Where can I find opportunities to affirm this patient and communicate a nonjudgmental attitude in order to build trust? When should I be transparent about the potential benefits of checking, documenting, or discussing weight?

• Peer support: Who in this patient’s life might offer them support as they navigate the health care system? How can I leverage this network when building a partnership? What can I learn from community resources, such as body-positivity activism?

• Empowerment, voice, and choice: What steps will I take to level the power dynamic between myself and my patients? How can I ensure the patient has a choice about if and/or when weight (and related topics, such as nutrition, physical activity, or weight loss) will be discussed?

• Collaboration and mutuality: How can I discover and center the patient’s agenda for their health? How can I adjust my language and behaviors during the encounter to aid in shared decision-making?

• Cultural, historic, and gender issues: In what ways might body size impact my patient’s sense of themself? How might this intersect with other identities they may hold? What assumptions am I making about the patient and where might these come from? How will I check myself to ensure that my biases do not impact their care?

These reflections can then direct clinicians’ and trainees’ behaviors, including framing of the encounter, interviewing and counseling, and performing a physical examination. More specific suggestions are outlined in the Table. Universal adoption of TIC practices when addressing body size will enable practitioners to improve psychological safety for all patientsand jettison unscientific approaches to care. A TIC model of inquiry that lends itself to clinical practice is more likely to address the underlying issues informing patient presentations.

Table:

Recommendations for trauma-informed discussion of body size in clinical encounters.

SAMHSA’s 6 guiding principles to a trauma- informed approach	Framing the encounter	Interviewing and counseling	Physical exam
Safety	Consider structuring trauma screening questions in a manner that allows patients to share how trauma has impacted their relationship with their body. “In your experience, have past traumatic experiences had a lasting impact on your physical or mental well-being?” Create a physically safe space, from the waiting room to the examination room. Ensure that chairs, examination tables, and other furniture can accommodate patients of all sizes; ideally, exam tables should be motorized.	Promote psychological safety by using neutral, nonmedicalizing, and person-first language. Emerging research suggests that language around “weight” rather than “obesity” may be preferred by patients. Other patients may prefer terms like “fat.”7 “I’m concerned that your A1C has increased from the last time. Would you be open to discussing weight loss as one part of our strategy for better blood sugar control?”	Ensure that correctly sized garments (drapes, gowns) and equipment (blood pressure cuffs, specula) are available and that clinic staff are trained to use them.
Trustworthiness and transparency	If discussion of the patient’s weight is medically relevant, communicate this clearly and compassionately at the onset of the visit, when the patient is seated and clothed. “As we discuss your arthritis symptoms today, I wanted to touch on weight loss as one strategy that could help. Would you be open to talking about that?” Avoid bringing up weight-related topics abruptly.	Use affirming language to establish trust. “I know weight can be a complicated topic for many. I will only bring it up as it pertains to your health.” Where possible, nonjudgmentally offer a menu of alternative treatments that do not involve weight-related interventions. “To relieve the pain in your knee joints, we could try lifestyle changes, physical therapy, or injections. Would you like to talk about any of these options?”	Explain examination maneuvers and prepare patients for sensations they may experience, especially maneuvers that may not be at eye level of the patient. “As a part of the skin exam, I will look in between skin folds for any signs of skin breakdown or rash. You will feel my gloved hand moving the skin apart, and it should not be uncomfortable or painful. Please let me know if it is and I will stop immediately and readjust.” Anticipate if standard physical examination technique will need modification to accommodate the patient’s habitus (eg, longer visit, modified maneuvers, doppler for pulses). Plan for anticipated modifications ahead of time to ensure the patient’s experience is respectful and professional.
Peer support	Include messaging in the appointment scheduling platform to indicate that patients are encouraged to bring a chaperone, friend, or loved one if desired. (Although this trauma-informed intervention is applicable to many patients, clinicians may not have considered its utility in this particular context).	When asking history questions about diet and exercise, seek to understand the role of the patient’s peer and social networks to better contextualize any lifestyle counseling. “Do you usually eat and exercise with others or by yourself?”	If the patient brings a support person, ask where they would like that person to be situated during the exam and what they can do to be most supportive.
Empowerment, voice, and choice	Create opportunities for flexibility and choice throughout the clinical encounter. For example: “We have a weight measurement recorded in the past 90 days, so it is your choice whether you’d like to be weighed today,” or “As we monitor your diabetes, getting a weight measurement today would provide us with helpful information to optimize your treatment. Does that sound ok? We’ll make sure we give you time to take off your layers and shoes, and you can step onto the scale backward if you’d prefer not to view the measurement.” Clearly indicate that patients may still decline to be weighed if they choose.	Ask patients to share their understanding of their illness and their own opinion about whether it is related to weight. “How did this all begin? Is there anything else related to your body or your health that affects this?” Offer patients individually tailored treatment plans and practicing evidence-based medicine. “Guidelines recommend trying weight loss as the first-line treatment for PCOS, but I hear and respect that you can/do not want to engage in a weight loss regimen now. We can start instead by trialing an oral contraceptive pill or anti-androgen medication. I am here to work with you.”	Remind the patient that their comfort and consent comes first and that the medical team values their voice. “If at any point, you feel pain or discomfort during the exam, let me know and I will pause immediately.” If assistance is required with positioning body habitus during the exam, first give the patient the opportunity to attempt re-positioning themselves. “I’m having some trouble seeing in order to place the speculum. Could you lift and hold the skin of the lower abdomen?
Collaboration and mutuality	Set an agenda for each visit by asking patients what they would like to discuss. If a patient does not bring up weight and it is not clinically pertinent to this visit’s chief concern, refrain from steering the conversation toward this topic.	In situations where weight loss is indicated, refrain from prescribing a weight loss plan and instead offer it to patients as an open-ended option. “In situations like yours, weight loss is often helpful. What are your thoughts on weight loss?” Express gratitude for the patient’s collaboration. “Thank you for coming to this appointment. Your input is the most important part of your treatment plan.”	Ask patients to share their preferences. “What would help you feel safe and comfortable during the exam?” Provide patients with opportunities to share prior experiences. “Have you had any exams in the past that caused discomfort, so that I can be mindful to avoid that?”
Cultural, historic, and gender issues	Demonstrate respectful curiosity about a patient’s relationship to their body in nonmedical contexts. Inquire regarding the patient’s preferences for discussing weight with their practitioner, preferred terminology, and any other pertinent background. “Many people have complicated, evolving relationships with their bodies and weight. I’d like to be able to discuss these topics with you in a manner that respects your boundaries but also allows me to take good care of your health. What is important for me to know to be able to do that?” Be mindful of a patient’s intersectional identities and how they may relate to body image. Allocate time to interrogate your own biases and develop a plan to ensure that they do not interfere with your care. Provide patients with space to discuss identity and bodily changes with you. Use affirming language. “How do you feel about these new changes to your body after starting testosterone?” or “I hear you. Along with so much else, your body also continues to change in the postpartum period. Sometimes it can be overwhelming to see a body in the mirror that is so different from the one you were used to. I am not concerned about your weight from a medical perspective, but I am here if you want to talk about this.”	Cocreate clinical recommendations that are respectful of patients’ background. “Thank you for sharing with me the role of rice in your family’s diet. As we incorporate more low-glycemic foods into your meals, I definitely want to make sure you can continue to enjoy this staple with your family! What would you think about reserving rice for dinners, and replacing some of the other portions with your favorite vegetable?” Affirming and applauding patients for taking positive steps despite personal barriers. “I’m really happy to hear you are enjoying this yoga class and moving your body! I remember at our last appointment how nervous you were to try it. Physical activity, even without weight loss, is good for your health.”	Recognize signs of distress throughout the exam and pause as appropriate. "I'm noticing you're tensing up. Are you alright?" Be mindful of draping to ensure that the minimum body surface is exposed at any time, and allow patients to keep clothing on when possible (for example, asking the patient to raise their shirt to facilitate inspection of a mole rather than removing their shirt entirely). Encourage them to move their own clothing/draping as needed, rather than you reaching to do so. Offer gowns in fabric and all sizes rather than the paper ones in standard size. Provide privacy when patients are dressing/undressing. Refrain from commenting on the person’s physical appearance, particularly when the comment places a value judgment (eg, avoid comments like, "You look great!" after a person has lost weight). If a patient’s weight loss or gain comes up during the examination, respectfully inquire about their reaction to navigating the world in a changed body. "How is this working for you?"

PCOS, Polycystic Ovary Syndrome.

Incorporating opportunities to adopt trauma-informed behaviors across the trajectory of medical training, from undergraduate to graduate to continuing medical education, is also of paramount importance. Data indicate that weight bias is rampant early in training: An implicit association study of medical students found that 70% held a thin preference, 74% attributed large body size to ignorance, and 28% thought people with large bodies were lazy.²⁷ To disrupt these biases, preclinical curricula can address the epidemiology and physiology of trauma, including its influence on the body. Clinical skills courses should teach about trauma-informed interviewing, physical exam, and documentation techniques and explicitly discuss their relevance to patients of size. Hospital clerkships should incorporate time to reflect on the impact of weight bias in medical decision making and empower students to employ trauma-informed principles when working with real patients. When developing didactic materials, educators may draw from literature regarding trauma-informed medical education in addition to resources that specifically focus on patients of size.^28,29 Patient perspectives should be centered throughout the creation and implementation of such content. For example, educators can draw from literature written by scholars of size or actively solicit feedback from this patient community.

Intentionally addressing this topic can empower students and clinicians to notice and question the entrenchment of weight bias throughout training and in their careers, thus encouraging thoughtful consideration of how stigma may unduly influence the proper course of patient care. TIC may increase practitioners’ empathy as they seek to understand patients’ stories and anticipate their needs. In addition to promoting patient-centered care, TIC also emphasizes self-care and self-reflection among its practitioners. Students and clinicians are not immune to the societal influence of weight bias, and many clinicians have written about their own devastating experiences with weight bias in medical settings.^15,30 TIC can help mitigate these harms and facilitate a supportive environment for everyone, not just patients.

Importantly, although our recommendations focus primarily on interventions at the individual (ie, identifying and lessening personal biases) and interpersonal (ie, optimizing communication during the clinician–patient encounter) levels of health care, multilevel initiatives are necessary to address weight stigma fully. For example, strategies targeting systemic bias (including the National Association to Advance Fat Acceptance’s advocacy for legal protection against weight discrimination³¹ or societal perception of body size (such as Google’s Plus Size Insights initiative to “more positively and authentically” represent people with large bodies in marketing materials³²) are manifestations of TIC beyond the clinic.

TIC is an opportunity to understand our patients better, empathize with their experiences, and provide more comprehensive care. Ultimately, it will empower clinicians with an approach to working with patients of diverse body sizes in a manner that is affirming and therapeutic, guiding patients in embracing and honoring their bodies.